| NPI | 1164099669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 20A20995) |
| 207Q00000X Family Medicine (Licence: AZ 011026) | |
| Enumeration Date | 2021-06-04 |
| Last Update Date | 2026-05-12 |